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October 12, 2016 – More great neurology cases….

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I rose well before sunrise this morning to catch up on my writing. These mornings are so pleasant with the soft sounds of the awakening day outside between the many birds and other animals along with the sometimes far off shouts of the villagers traveling to or from their early destinations. The cool mornings have been a bit much to sit outside and write these days which is fine as our house is so cozy. I can’t wait for the Raynes House to be finished and ready for our occupancy, which should be by March, as it will give us a base for our continued work here. We will have a home to return to each visit.

As the days of the week roll on, the volume of the outpatient clinic lessens slightly as do our neurology patients and it seems like we are making some headway working through the numbers that we must see. We still have more than enough patients, though, to send a few home each day to return the following morning and be seen at the front of the line. Our patient flow also has improved in that our patients are now sent directly over to our waiting area where they can be screened and have their vital signs taken by nurses in a small room just outside the emergency room. This system is working so much better and it is clear that the patients are much happier not having to be walked back and forth in the process. This will clearly work well in the future.

We all ran up a few minutes early to attend to emails and texts as the only internet is up at the administration building and my phone works best there as well. Laura and Kelley attending morning rounds to hear how the ward patients were doing while I posted my blog and got things together for the days clinic. In addition to seeing whether there is any “business” for us on the wards, the two of them have much to add from a medicine standpoint given that they are so close to their intern years and mine was thirty years in the past. When I went to retrieve them from the ward as we were ready to see patients, they were discussing some non-neurologic aspects about a patient with Dr. Badyano which was great as I know that their contributions are very much appreciated by the staff here.

Kelley’s second patient of the day was another fascinating patient. We are seeing disorders here that they rarely, if ever, get to see at home so the experience here is invaluable. A 26-year-old Maasai man was brought in by his mother and the story was that he was well until after he underwent his circumcision ceremony at age 14, following which he began to develop leg weakness and difficulty walking. The Maasai circumcision ceremony is performed only every seven years and is one of the most revered of ceremonies they have as it is the time that the young men will leave their boma and go into the wilderness to become warriors. They used to have to kill a lion for this ritual, but that is obviously no longer the case. The other interesting nuance to the story is that everything here is always related to an event that occurred in the past as it is the only way they have to relate something in time. The passage of years is very difficult to convey in a story, but the relationship to an event is much easier.

Checking cerebellar function in our patient with a spinocerebellar ataxia

After hearing the history, both Kelley and I were fully expecting the young man to have a neuromuscular problem such as muscular dystrophy, but in the end it was quite different from that. He was cognitively intact so that part of the exam didn’t lead to any new discoveries. The next part of the exam is to look at their fundus with the ophthalmoscope and when Kelley did that she thought the patient kept moving his eyes, but quickly discovered that it wasn’t his fault as he had nystagmus. Nystagmus is the subtle, or at times not so subtle, movement of the eyes and there can be various types of nystagmus. The important part, though, is that it indicates a central nervous system problem. So, from the outset of her exam it was clear that the problem wasn’t going to be a neuromuscular one, but rather a central nervous system disorder. Given the issue at hand, that is, his problem walking, we both immediately knew that his strength was going to be normal and source of his deficit would not be what we had both initially expected. He had dramatic cerebellar dysfunction, or ataxia, on every aspect of his examination and it was great that we were seeing him with Dr. Ken so he would clearly recognize this in the future. He even recalled the lecture he had been given in assistant medical officer school from which he recently returned that dealt with the ataxias and cerebellar dysfunction. I had seen a similar patient last week and regretted that the residents were here to see them, but here we had another patient with this rare group of disorders classified as the spinocerebellar ataxias. Kelley’s patient had loss of reflexes, though, as opposed to my patient who had clear evidence of corticospinal tract involvement so the two patients were very likely different versions of this group of disorders that are usually sorted out by doing genetic testing in the US. That obviously is unavailable here, but in reality it primarily serves to help with genetic counseling rather than with any treatment of which there are none. These are progressive disorders that eventually become quite disabling. We provided the counseling we could and the fact that this was something that could be passed on to his children as he was planning to be married shortly. Given his young age and the amount of difficulty he had walking at the present, it will not be long that he will need significant help getting around.

Kelley also had a very interesting Parkinson’s patient who was on carbidopa/levodopa already, but his dosing schedule was the problem. He had profound tremor that was actually responding to the medication as was his rigidity, but he was taking his medications only twice daily and a large amount with each dose so as to be causing him nausea. It was just a matter of scheduling his dosing to every four hours during the day with a smaller dose each time and he will tolerate his medication much better and it will work much more effectively throughout the day. This adjustment is not that different than what we often do in the US when Parkinson’s patients come to us and have been placed on the wrong dosing schedule.

Laura’s experience of the day was with interesting patients presenting often with complaints that also belied their true underlying problem. Multiple patients come complaining of memory loss and when you delve further into their history, it is really a psychiatric issue. We have seen a number of young patients who present with symptoms very suggestive of schizophrenia or schizoaffective disorder and are brought by their families to see us. Psychiatric care here is very primitive and most patients we see with these issues have never been truly diagnosed or even seen for their problem. We do have reasonable medications to treat them with for their psychosis and are able to explain to the family what the underlying problem is. It is also unfortunate that for most of them, this is a lifelong problem that can only be treated symptomatically and will never be cured. Laura also saw two young patients coming in with complaints of headache that also turned out to be something far different as both actually had epilepsy and were having recurrent seizures. After taking a thorough history and sorting out the details, the patients were put on medications and told to return for follow up to let us know how they were doing. Hopefully we will see them back and be able to adjust their medications as this is so often the problem here. We see so many patients in follow up who when we ask if they are still taking their medications, they tell us they are “over” meaning that they took their month of medication and despite having been told to come back for refills, they merely stopped them. It is often a cultural bias regarding the idea of taking chronic medications, but is also often related to being able to afford them. We have worked on a system for the neurology patients to be subsidize some of the cost of the medications as making a diagnosis of epilepsy or migraine and having the patients only take their medicine for a month or even two does not work well. Sokoine meets with the patients and their families after the visit to discuss with them what they can afford and we try to make sure they are aware that we will try to help them when they return for refills. Sometimes it works well and other times not so well. The effort is being made, though, and that is what counts.

Our day finished around five and today the staff working with us found a ride back to town so I didn’t have to make another trip to get everyone home. We got home early enough to relax on Joyce’s veranda and watch the sunset, which is always gorgeous, though quickly leads into the flood of mosquitoes with the darkness. Even with the bats flying low over our heads to devour the insects and fill their bellies before returning to their homes, we are bitten enough to eventually be forced back inside our houses where we ate our prepared dinners in comfort. Tonight was roast pork, cauliflower and we think perhaps sliced cassava or possibly breadfruit. We couldn’t be sure on the latter, but it was tasty and much appreciated just the same. It was off to an early bedtime and thoughts of another wonderful day in this amazing paradise.

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One thought on “October 12, 2016 – More great neurology cases….”

Karen Humbert

Once again, thank you so much for the blogs. I look forward to them every day. After reading how difficult it is with the internet situation I am even more grateful. Please don’t worry about answering me, I just want you to know that I read every word and love every picture! Have a great day. Much love and good wishes….Karen